I read with interest the recent article by Udani V, et al.(1).
Based on a well-conducted retrospective study on infants presenting with
hydrocephalus, they conclude that neonatal meningitis/ventriculitis
remains undiagnosed in about a third of newborns with this condition.
However, I would like to make certain observations.

Hydrocephalus is but one of the several sequelae of
neonatal meningitis (NM). Other common sequelae include mental
retarda-tion, seizures, and sensorineural hearing loss(2). Therefore,
studying cases of hydro-cephalus alone may not reflect a true picture of
unrecognized NM and figures thus obtained may under-estimate the
proportion of missed cases. In fact, in the present series too, 4/13
infants presenting with hydro-cephalus had seizures also. Further
studies are required to determine the proportion of cases of infantile
seizures where unrecog-nized NM could be a contributing factor.

There could be various factors that lead to a missed
diagnosis of NM. Authors highlight the problem of inadequate antibiotic
administration (less than three weeks) for suspected "sepsis", resulting
in only partial treatment of meningitis. Other reason could be the
absence of classical symptoms and signs of meningitis. It was observed
that dyspnea was the commonest clinical manifestation among newborns
presenting with meningitis before seven days of age, whereas fever and
diarrhea were the commonest manifestation among those presenting after
seven days(3). In the current series too, about 60% of infants did not
have usual symptoms of infection.

Lumbar puncture (LP) is not routinely performed in
evaluation of early neonatal sepsis due to several factors such as that
it is an invasive procedure, it may compromise respiratory function, and
interpretation of cerebrospinal fluid analysis may not always be
straightforward(4). However, omitting LP could result in delayed or
missed diagnosis of NM in about 40% of cases(5). Therefore, LP should be
included in evaluation of all high-risk newborns presenting with sepsis.

Authors report a poor outcome in majority of their
cases of NM with hydrocephalus. Seven of 11 (63%) patients for whom
follow up data was available had a severe disability. Delayed diagnosis
and inadequate treat-ment, according to the authors, is responsible for
this. However, due to a "retrospective hospital-based" nature of this
study, it is likely that patients with favorable outcomes did not return
to the hospital. Small sample size is a further limitation to this
conclusion.

In conclusion, the current study has convincingly
highlighted that NM is commonly undiagnosed or diagnosed late. This
could be a significant factor leading to a higher morbidity and
mortality in this group of newborns. LP should be performed in all
high-risk cases with neonatal sepsis to avoid missing NM.